Routine structured risk assessments reduce ward aggression, seclusion
MedWire News: Regular use of short-term structured risk assessments reduces the number of aggression incidents and the use of restraint and seclusion in psychiatric wards, show study findings.
"Regular process evaluations and team feedback on risk identification and advanced critical thinking about the necessity for coercive interventions would improve the level of decision-making on psychiatric admission wards," say R van de Sande (University of Applied Science, Utrecht, the Netherlands) and co-authors.
In total, 597 patients in four wards were randomly assigned to receive daily structured risk assessment or treatment based on clinical judgment (treatment as usual [TAU]) over a 40-week period.
Patients were assessed daily using the Brøset Violence Checklist and a short version of the Kennedy-Axis V, with weekly assessments performed using the full version of the Kennedy-Axis V, Brief Psychiatric Rating Scale (BPRS), Dangerousness Scale, and the Social Dysfunction and Aggression Scale.
All scales were fully incorporated into short-term clinical decision-making, intervention planning, and evaluation. In addition, the Crisis Monitor was used for early recognition of patterns associated with evolving escalation and symptom severity changes. Scores were then used to guide discussions on how to deal with observed changes in risks.
A significantly lower risk for aggression incidents and the number of patients engaging in aggressive behavior was seen on the two wards assigned to the intervention compared with those receiving TAU (relative risk reductions [RRRs]=68 and 50%, respectively). Indeed, the number of aggression incidents per week decreased significantly from 4.9 at baseline to 1.7 during the intervention, while thechange in the control group was nonsignificant (3.5 to 3.9 incidents per week).
Patients assigned to the intervention also spent significantly less time in seclusion compared with controls (RRR=45%). A 15% decrease in the number of seclusion incidents was also observed, although this was not significant.
"This suggests that seclusion could be prevented in several instances, but it seems likely that the constant monitoring of the symptoms and risk was helpful in substantially reducing the length of time spent in seclusion," comment the researchers in the British Journal of Psychiatry.
After controlling for patient characteristics, regression analysis showed that both short-term and long-term involuntary admission and psychotic disorder were negatively associated with time spent in seclusion. Being aged less than 35 years also showed a significant positive association with time spent in seclusion.
In addition to the lack of extra staffing costs observed with the intervention, the team says that "data generated from risk assessment scores might improve individualized treatment plans as well as ward policy-making in general."
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By Ingrid Grasmo